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Avalere Health projects 26 states will not expand their Medicaid programs next year or are leaning in that direction, meaning 5.3 million fewer people will gain access to the program. In states with expanded access, the additional patients gaining coverage could strain primary care systems, but Avalere vice president Caroline Pearson said alternative plans, such as the premium assistance model approved in Arkansas, may reduce physician shortages.

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An Avalere Health analysis found that premiums for an average health insurance policy have come in lower than expected in nine states that have unveiled data on their health insurance exchanges' initial rates. "The initial data suggest that competition in exchanges is working to lower premiums, which will benefit nonsubsidized enrollees and the federal government," Avalere Health Vice President Caroline Pearson said.

The American Dental Association is urging states to expand Medicaid dental benefits for adults. An estimated 5.3 million adults will gain dental benefits under the Affordable Care Act, but most will be in the handful of states that provide extensive Medicaid benefits and will expand eligibility under the law. Care coordination and reducing compartmentalization can also help, the group said.

State governments that have said they will not expand Medicaid eligibility under the Affordable Care Act are not likely to change their minds this year, according to a recent statement from Caroline Pearson at Avalere Health. Some movement looked possible in Tennessee, Florida, Kentucky and New York, but state legislative sessions are winding down, and the Obama administration has few tools available to turn the tide.

Lawmakers in Tennessee and Montana might follow Arkansas' model in expanding Medicaid eligibility by using Affordable Care Act funding to enroll some beneficiaries in commercial health plans. However, they and other states have not performed cost estimates or crafted firm proposals and are likely to move less quickly than Arkansas in passing alternative plans, says Avalere Health's Caroline Pearson.

States that decided not to run their own health insurance exchanges by themselves may yet decide to run one in partnership with the federal government, and many are still deciding whether to expand Medicaid eligibility. Arizona, Arkansas, Florida, Idaho and Maine are of particular interest as they negotiate internally and with HHS on Medicaid and exchanges.